T2 L7 Causes and treatment of subfertility Flashcards
What are the requirements for conception?
Progressively motile normal sperm that are capable of reaching and fertilising oocyte
Timely release of competent oocyte
Free passage for sperm to reach oocyte and for embryo to reach uterus
Mature endometrium that allows implantation
What is the definition of infertility?
Inability to conceive after 2 years of frequent, unprotected intercourse
Period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented
What is the cumulative probability of pregnancy after 1 year?
84%
What is the cumulative probability of pregnancy after 2 years?
92%
What is the cumulative probability of pregnancy after 3 years?
93%
How many couples will have a problem conceiving?
1 in 6
What is the causes of infertility?
Unexplained - 30% Ovulatory - 27% Male factor - 19% Tubal - 14% Endometriosis - 5% Other factors - 5%
Why does women’s fertility decline with age?
Decline in oocyte number and quality rather than uterine receptivity
What are the indications for early referral / investigations in females?
Aged over 35 years Amenorrhoea / oligomenorrhoea Previous abdominal / pelvic surgery Previous PID / STD Abnormal pelvic examination
What are the indications for early referral / investigations in males?
Previous genital pathology - history of testicular maldescent surgery, infection or trauma
Previous STD
Significant systemic illness
Abnormal genital examination
Describe the results of a normal semen analysis
Count > 15x10^6/ml
Motility >40%
Morphology >4%
Volume 1.5-6mls
What are the causes of abnormal semen analysis?
No reason in 50%
Primary testicular failure is commonest cause for oligo/azoospermia
Obstructive or non-obstructive azoospermia
Y chromosome micro deletion and cystic fibrosis if sperm count <5 million
Describe a female assessment
Screen for chlamydia and rubella Ovarian reserve - early follicular phase hormone level - AMH - AFD Ovulation test Tubal test
What is anti-mullarian hormone (AMH)?
Produced by granulose cells of pre-antral and small antral stages
Levels of AMH are constant through monthly but decline with age
Higher AMH levels predict a good response
Lower AMH levels predict a poor response
How can women monitor their ovulation?
Basal body temperature
Ovulation detection kits
Cervical mucous pattern
Follicular tracking or mid-literal phase P4
What does the result of a mid-luteal P4 need to be for evidence of ovulation?
> 30nmol/L
What levels should be tested in oligo/amenorrhoea?
FSH / LH E2 Prolactin TFT Androgens SHBG
What is the commonest cause of a loss of tubal potency?
Pelvic inflammatory disease secondary to chlamydia
What is the risk of tubal damage after 1 episode of pelvic infection?
12%
What is the risk of tubal damage after 2 episodes of pelvic infection?
23%
What is the risk of tubal damage after 3 episodes of pelvic infection?
54%
What are some other causes of tubal disease?
Septic abortion
Ruptured appendix
Pelvic surgery
Ectopic pregnancy
What is a hysterosalpingogram?
Procedure using X-ray to look at Fallopian tubes and uterus
When should a hysterosalpinogram be done?
2-5 days after menstruation
What are the advantages of a hysterosalpingogram?
Relatively safe
Ease of use
Delineation of uterine cavity and Fallopian tubes
What are the disadvantages of a hysterosalpingogram?
Inability to assess pelvic peritoneum
What is a hysterosalpingo-contrast-ultrasonography?
Assess fallopian tubes
Similar to HSG
No radiation
Describe the benefits and risks of using laparoscopy and dye for investigations
Invasive procedure with risks of visceral injury to the patient
More sensitive and specific
Chance to diagnose and treat endometriosis and adhesions
What can be used to induce ovulation in women with polycystic ovaries?
Clomid (clomifene citrate)
FSH injections for resistant PCO of hypogonadotrophic hypogonadism
What are the indications for IUI treatment?
Unexplained
Mild male factor
Mild endometriosis
What is the benefits of IUI treatment?
Less stress
Less invasive
Less tech
Cheap
What is the success rate of IUI treatment?
10% per cycle
What are the NICE guidelines for IUI treatment?
Don’t offer IUI for couples with unexplained infertility
IUI for single women, same sex couple or heterosexual couple who have problems with intercourse
IVF for couples with unexplained infertility
What is IVF used for?
Tubal damage
Low sperm quality
Unexplained infertility
Low ovarian reserve
What are the steps of IVF?
Controlled ovarian hyperstimulation Egg collection IVF ICSI Embryo development Embryo transfer
What is the success rate of IVF?
Depends on female partner’s age
Varies from one unit to another
National average is 30-35% for those below 35 years old
